Sacubitril-Valsartan Improves Blood Pressure and Heart Failure in Left Ventricular Assist Device (LVAD) Patients

Abstract

Angiotensin receptor neprilysin inhibitors (ARNIs) are not routinely used in patients following left ventricular assist device (LVAD) implantation. At our center, we have increasingly adopted ARNI use in LVAD patients. The objective of this study was to investigate the effects of ARNI therapy on LVAD patients. Stable LVAD outpatients with hypertension and persistent heart failure symptoms were initiated on ARNI therapy at our center. We retrospectively reviewed medication requirements and clinical parameters pre- and 3-months post-ARNI initiation. Twenty stable LVAD outpatients were initiated on sacubitril-valsartan in an effort to improve blood pressure control and heart failure symptoms. Of these 20 patients, 10 (50%) were maintained on 24/26 mg BID dosing, 6 (30%) were uptitrated to 49/51 mg BID, and 4 (20%) to 97/103 mg BID. Three months following ARNI initiation, mean arterial pressure improved from 92±24 to 75±19 mm Hg (P<0.001). ARNI allowed for significant dose reduction in calcium channel blocker dose burden (nifedipine 56±60 to 30±48 mg/day, P=0.02; amlodipine 3±4 to 0±2 mg/day, P=0.06). ARNI also facilitated a significant reduction in loop diuretic requirement (furosemide equivalent of 132±136 to 80±65.6 mg/day, P=0.004). There was an overall improvement in New York Heart Association Functional Class (2.6±0.8 to 1.6±0.7, P<0.001). Renal function did not appreciably change (Creatinine 1.3±0.5 to 1.3±0.3 mg/dl, P=0.76). There was a trend towards reduced left ventricular diastolic diameter (6.1±1.0 to 5.7±1.1 cm, P=0.13). Six patients experienced an unremitting side effect requiring ARNI cessation (dizziness/hypotension, 3; LVAD suction, 2; cough, 1). ARNI can improve blood pressure, decrease diuretic requirement, and improve functional capacity in LVAD patients. LVAD speed and medication adjustments may be necessary following ARNI initiation, and in some instances, side effects can limit the ability to sustain ARNI therapy in the setting of LVAD.